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Aug. 26, 2011 -- Experts say the fight against childhood obesity should have a new focus: day care.

Studies show that about 82% of American children under age 6 are in child care outside the home while their parents work.

That means many meals are no longer eaten around the family table, but at day care, where parents may have little control over what toddlers are eating.

Kids in full-time day care can get two-thirds of their daily calories there, “so it’s really other adults who are driving the nutritional value of what children consume,” says study researcher Sara Benjamin Neelon, PhD. She's an assistant professor in the department of community and family medicine at Duke University Medical Center in Durham, N.C.

In a new study, published in the Journal of the American Dietetic Association, Benjamin Neelon and her colleagues reviewed 42 studies of obesity prevention related practices in day care.

They found that most states have minimal requirements for healthy eating and physical activity in child care that may differ from public health expert recommendations. Experts who were not involved in the research praised its scope and said that while it points to substantial problems, it also suggests that day care can be an important place to make lasting changes in a child’s life.

Starting Young

“In general, there’s been an increasing awareness that we have to start tackling obesity very early in a child’s life,” says Alice Ammerman, DrPH, a nutrition professor and director of the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill.

“I think things are moving in the right direction, but I think there’s a lot of potential for greater improvement,” particularly through day care, Ammerman says.

Day Care Menus

Day care centers that qualify for government financial assistance must meet guidelines that call for kids to get foods high in nutrients but low in fat, sugar, and salt.

But studies have shown that some day care centers fall short of meeting those standards.

For example, in Texas, research was done at nine child care centers to determine if meals served provide children with enough grains, fruit, vegetables and protein to meet 1/2 to 2/3 of the daily amount recommended by federal nutrition guidelines. Researchers found that less than half of 3-year-olds got enough grains, vegetables, or dairy to meet 1/2 the daily recommended amount. Two out of three children ages 4 and 5 only got enough dairy to meet half of the dairy recommendation, but fewer than half got the recommended amount for any other food group. What’s more, the meals kids ate at home did not fully replace missing nutrition during child care.

Promoting Healthy Eating

Other studies have looked at mealtime behaviors promoted by day care centers.

Head Start programs, for example, direct care providers to model healthy behaviors by sitting with children at meals and eating the same foods. Studies show that most centers in the program are following that advice.

But other studies that recorded conversations between day care attendants and kids found that few coached the children to heed feelings of hunger or fullness.

Adults made 10 times more comments about how much or how little food the child was eating, without asking whether kids felt like they had eaten enough.

“If we can encourage them to listen to their internal cues, we can prevent them from overeating,” says Benjamin Neelon. “We don’t interfere by saying, 'You have to have two more bites or you have to clean your plate,'” she says.

Physical Activity Lags

Many kids aren’t very active when they’re in day care, with kids rarely getting the recommended 60 minutes of moderate-to-vigorous daily activity, the review shows. However, the children's physical activity levels were found to vary depending upon the child care facility attended.

In one of the reviewed studies, children were sedentary more than 80% of the time that they were being observed.

Studies suggest kids don’t get much exercise because staffers fail to encourage it, or they may even take physical activity away as punishment, as in the infamous "time out."

What Parents Can Do

Carefully choosing a child care center is key.

“You’ve given control of your child’s food to the child care center and therefore it’s really important that if you can, you select that center very carefully,” says Margaret Briley, PhD, RD, LD, a nutritional science professor at the University of Texas at Austin. Briley wrote a commentary on the new study but was not involved in the research.

Look at the setting. Centers that have outdoor play areas and few television or computer screens encourage more physical activity.

Larger child care centers are subject to more specific regulations for food and physical activity than home-based child care centers.

Ask how food is served. Meals dished up family-style, where kids can help themselves to bowls of food, teach kids how to take responsibility for what’s on their plate.

“It kind of gives them a better sense of what to eat, rather than giving them a big of pile of something they may not really want,” Ammerman tells WebMD.

Ask to see a menu. “When you look at a menu, you can look at a couple of things at a glance. Are children served the same thing every Tuesday-Thursday? That’s not a lot of variety,” Benjamin Neelon says. More variety means more nutrients.

Fried foods -- including chicken nuggets, fish sticks, and french fries -- should be another red flag.

Talk to the staff. Ammerman recommends starting a dialogue with the day care staff about how kids are doing at mealtimes and whether they’re willing to try new things.

That feedback can be helpful at home, too. If a child who never eats beans at home loves the beans at day care, get the recipe, she says.

“Like any sort of parental thing, being engaged in the process is half the battle,” Ammerman says.